|Year : 2013 | Volume
| Issue : 4 | Page : 159-164
Clinical presentation, management and outcome of acute coronary syndrome in Yemen: Data from GULF RACE - 2 registry
Al-Motarreb Ahmed, Al-Matry Abdulwahab, Al-Fakih Hesham, Wather Nawar
Department of Internal Medicine, Faculty of Medicine, Sanaa University and Cardiac Centre, Al-Thawarah Hospital, Sanaa, Yemen
|Date of Web Publication||12-Feb-2014|
Department of Internal Medicine, Faculty of Medicine, Sanaa University, Sanaa
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Acute Coronary Syndrome (ACS) is increasing in Yemen in recent years and there are no data available on its short and long-term outcome. We evaluated the clinical pictures, management, in-hospital, and long-term outcomes of the ACS patients in Yemen.
Design and Setting: A 9-month prospective, multi-center study conducted in 26 hospitals from 9 governorates. The study included 30-day and 1-year mortality follow-up.
Patients and Methods: One thousand seven hundred and sixty one patients with ACS were collected prospectively during the 9-month period. Patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndrome (NSTEACS), including non-ST-elevation myocardial infarction and unstable angina were included .
Conclusions: ACS patients in Yemen present at a relatively young age with high prevalence of Smoking, khat chewing and hypertension. STEMI patients present late, and their acute management is poor. In-hospital evidence-based medication rates are high, but coronary revascularization procedures were very low. In-hospital mortality was high and long-term mortality rates increased two folds compared with the in-hospital mortality.
Keywords: Acute coronary syndrome, khat chewing, mortality, registry
|How to cite this article:|
Ahmed AM, Abdulwahab AM, Hesham AF, Nawar W. Clinical presentation, management and outcome of acute coronary syndrome in Yemen: Data from GULF RACE - 2 registry. Heart Views 2013;14:159-64
|How to cite this URL:|
Ahmed AM, Abdulwahab AM, Hesham AF, Nawar W. Clinical presentation, management and outcome of acute coronary syndrome in Yemen: Data from GULF RACE - 2 registry. Heart Views [serial online] 2013 [cited 2018 Aug 15];14:159-64. Available from: http://www.heartviews.org/text.asp?2013/14/4/159/126880
| Introduction|| |
Cardiovascular disease remain the leading cause of death in the world and have increased at an astonishingly fast rate in low- and middle-income countries. More than 17 million people died from cardiovascular diseases in 2008.  Acute coronary syndrome (ACS) is the most common cause of cardiovascular mortality and morbidity in Western countries. The Gulf Heart Association launched a registry of ACS (Gulf RACE) in October 2008 until June 2009. Two ACS registries had been conducted and the main results have been published. ,
There are limited data on the presentation, management, and outcome of ACS admissions in Yemen. The Gulf Registry of ACS will highlight on this data in Yemen as part of the whole data from the Gulf countries. Gulf RACE is the largest multinational prospective ACS registry in the Middle East.
Data from Yemen was collected from 26 Hospitals in 9 governorates and 1761 ACS patients were enrolled. Baseline characteristics, management, in-hospital mortality and long-term outcome of the Yemeni patients are described.
Mortality among Yemeni patients in Gulf Registry of ACS (Gulf Race-1) was the highest among the Gulf states.  Many factors play a role in this mortality are a non-present and khat chewing are two important factors. Khat chewing is an independent risk-factor for acute myocardial infarction in Yemen.  It causes coronary and peripheral vasoconstriction  and associated with increased risk of stroke and death in patients with ACS.  Khat is associated with high morbidity, in-hospital mortality and late mortality.  Another explanation for high mortality is the lack of ambulance service.
| Patients and Methods|| |
The data were collected from a 9-month prospective, multi-center study in Yemen as part of Gulf RACE-2. ACS patients were recruited consecutively from 26 hospitals from 9 different governorates in Yemen with a diagnosis of ACS including ST-elevation myocardial infarction (STEMI), unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI). The last two diagnosis have been merged together as non-ST-elevation acute coronary syndrome (NSTEACS).
There is no patient-specific exclusion criterion, and all prospective patients with ACS were thus enrolled. The study received ethical approval from the ethical committee in the Ministry of Health in Yemen. Diagnosis of the different types of ACS and definitions of data variables were based on the American College of Cardiology clinical data standards. 
Central obesity was defined as a waist circumference of more than 94 cm in men and more than 80 cm in women. 
Data on the following variables were collected: Serum creatinine before hospital discharge, serum hemoglobin A1c; EF by echocardiography (severe left ventricular (LV) dysfunction, Ejection fraction (EF) <30%; moderate LV dysfunction: EF = 30-40%; mild LV dysfunction: EF = 40-55%; normal LV function: >55%). Coronary angiogram results (left main CAD, one-vessel disease, two-vessel disease, triple-vessel disease); and types of coronary artery stents used (drug-eluting and/or bare-metal stents).
Significant CAD was defined as ≥50% occlusion compared to the normal reference diameter in the left main and ≥70% in other major epicardial coronary arteries.
A report form for each patient with suspected ACS was filled out upon hospital admission by assigned physicians and/or research assistants working in each hospital using standard definitions and completed throughout the patient's hospital stay. Almost all the data variables were mandatory fields and completed online. All report forms were verified by a cardiologist and then sent online to the principal coordinating center, where they were further checked for errors before submission for final analysis. We avoided duplicate admissions to the registry by using patients' national identification numbers and assigned "registry numbers." Long-term mortality was obtained by either phone contacts or clinic visits.
Data were summarized as mean ± Standard Deviation (SD) if they were normally distributed; otherwise, they were summarized as the median and interquartile range (IQR). Differences between groups were assessed using Chi square or Fisher's exact tests for categorical variables, student's t tests for continuous and normally distributed variables, and the Mann-Whitney U test for skewed variables. All analyses were considered significant at P < 0.05. The analysis was performed using SPSS software, version 18.
| Results|| |
Between October 2008 and June 2009, 1761 ACS patients were enrolled. There were 1230 (69.8%) STEMI and 531 (30.2%) NSTEACS patients. The NSTEACS patients included 246 (46.3%) NSTEMI and 285 (53.6%) UA patients. [Table 1] shows patient's baseline characteristics and treatments. The mean age of the overall population was 58 ± 12 years, 79.2% of them were men. The prevalence of CAD risk-factors was high, in particular khat chewing and smoking; 77.1% were khat chewers and 72.1% were either current or ex-smokers. Followed by hypertension in 34.6% of the patients, diabetes mellitus in 23.2% of patients and 13.2% had hyperlipidemia. Mean body mass index (BMI) ± SD was 25.3 ± 4.3 kg/m 2.
|Table 1: Baseline characteristics of patient with acute coronary syndrome|
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Upon presentation, only 1.8% arrived at the hospital in an ambulance, 81.4% had typical ischemic chest pain, 8.3% had clinical evidence of congestive heart failure (CHF), and 77.1% had positive serum troponin. Serum troponin was unknown in 132(7.5%) patients as the treating physicians decided not to perform the test because the diagnosis of STEMI had already been made by electrocardiogram and elevated creatinine kinase isoenzyme (CK)-MB, or the test was not available at the time of admission.
Compared with STEMI patients, those with NSTEACS were more likely to be older and to have history of Percutaneous coronary intervention (PCI), coronary artery bypass graft surgery (CABG), peripheral arterial disease, CHF, ex-smoking, to present with Killip class >1, higher mean systolic blood pressure; higher frequency of intermediate Global Registry of Acute Coronary Events (GRACE) score category, to have severe LV dysfunction, undergo coronary angiogram, PCI, CABG.
However, STEMI patients were more likely to be men, had a higher BMI, and to present with typical ischemic chest pain, current smokers, khat chewers, hyperlipidemia, positive serum troponin, higher peak serum CK-MB fraction, total cholesterol and triglyceride, and/or left main and/or triple-vessel disease during hospitalization and low GRACE score category.
STEMI presentation and management
Five hundred and sixty nine patients (46.2%) out of 1230 STEMI patients presented within 12 h of symptom onset; Median time from symptom onset to hospital arrival 440 min (IQR: 195-900 min).
Only 337 patients (19.1%) out of 1761 patients were treated with thrombolytic therapy (TT), with only 27% (90 patients out of 337) receiving it within less than 30 min and the median door-to-needle time was 40 min (IQR 25-60 min).
The most commonly used TT was streptokinase (96%), followed by reteplase (2.7%), then tenecteplase (0.9%). These drugs were administered in coronary/intensive care units in 94.1%, and by cardiology specialists in 82.5% of cases. There was no clinical evidence of reperfusion in 22.3%, and rescue PCI was done in 0.2% of these patients. Reasons for not administering TT included: symptom onset more than 12 h before hospital presentation in (85%) of the patients, missed diagnosis in (3.9%), absolute contraindications (2.7%) and primary PCI (1%) and other causes (7.4%) such as unavailability of unavailability of TT, patient and/or family refusal, and patient inability to pay for cardiac care.
There was a high use of evidence-based medications in the first 24 h of hospital admission and at discharge: Aspirin (98.2% and 89.2%), Statins (93.6% and 87.4%), Clopidogrel (88.6% and 82.1%), Beta-blockers (63.4% and 67.1%), and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (74.5% and 73.6%).
Anticoagulation therapy, was given to the patients was in the form of intravenous unfractionated heparin for 84.3%, and enoxaparin 9.5%. No single STEMI case received bivalirudin or fondaparinux. Intravenous glycoprotein IIb/IIIa inhibitors (GP IIb/IIIa-I) were given in 2.3%, all of them in the form of tirofiban.
[Table 2] shows that Echocardiography was done in 81.3% of patients, with 76.1% having evidence of LV dysfunction. Coronary angiography in 11%, PCI in 4.4%, (more for NSTEMI than STEMI) and CABG in 0.1%. In PCI patients, bare-metal stents were used in 69.4%, drug-eluting stents in 27.8%, and both in 2.8%.
In hospital and long-term outcome
[Table 3] shows the in-hospital and long-term outcome; The most frequent complications were recurrent ischemia (28%) and CHF (19.5%), whereas rates of stroke (1.1%) and major bleeding (0.7%) were very low. The overall in-hospital mortality was 8.6%; STEMI patients had higher in-hospital mortality and cardiovascular complications except for major bleeding and CHF but had similar rates of stroke compared with NSTEACS patients. STEMI patients had more recurrent ischemia, recurrent myocardial infarction, cardiogenic shock, ventricular tachycardia and/ventricular fibrillation and in-hospital mortality. Overall 30-day mortality was 14.9% (16.2% in STEMI, 12.1% in NSTEMI/UA, and unknown in 12%). Overall 1-year mortality was 17.4% (18.6% in STEMI, 14.7% in NSTEMI/UA, and unknown in 14.5%).
| Discussion|| |
This paper is the first one to describe the ACS presentation, management and long-term outcome in Yemen. It is part of the Gulf registry of ACS phase-2. It reflects the general practice and management strategies in many hospitals and different governorates in Yemen.
Patients with ACS in this study have shown that almost 2/3 rd (69.8%) of them had STEMI compared with (45.6%) in the Gulf  and with 1/3 rd in other ACS population reported worldwide. , However, the rate of STEMI among ACS patients is higher than that of ACS patients from East Asia countries. 
The average age of ACS patients at presentation was 58 years, which is almost a decade younger than the presentation age in developed countries.  STEMI prevalence among our patients can be explained by high prevalence of khat chewing, which was shown to be associated with more STEMI than NSTEMI,  overall younger age of population and the priority of admission to hospitals was for STEMI is another possible reason, while those with NSTEMI are transferred to other hospitals and some of these hospitals were not involved in this study.
Patients with STEMI in our study took 440 min (IQR: 195-900) before presenting to the emergency department compared with 140-170 min in developed countries  and 178 min in the Gulf.  This reflect the absence of ambulance services for transferring patients to hospitals, lack of knowledge of the heart attack symptoms and absence of hospitals with intensive care facilities in many governorates and long travel distances needed for patients before arrival to a major cardiac center in the country. Therefore, only 19% of the STEMI patients received TT and only 27% of these patients received TT within less than the standard 30 min door-to-needle time. The majority of patients were delayed in the emergency department awaiting the approval of administration of TT by the Cardiologist in the coronary/intensive care units.
Our study shows that the most commonly used TT was streptokinase (96%), reteplase (2.7%), then tenectaplase (0.9%), the explanation of using the streptokinase in majority of cases is the availability of the drug and the low cost, while the other TT were very expensive and not available.
Primary PCI in Yemen is very limited and represented in this study with only 1% despite the presence of two hospitals with PCI facilities. This low percent of using PCI could be explained by many factors including late presentation to ER, delay at ER, Lack of PCI facilities hospitals, STEMI team is not available in particular overnight duties.
This should high light the importance of establishment of an effective and efficient program for people awareness about the symptoms of ACS and the importance of early arrival to the hospital, training the hospital training ER doctors for quick, efficient management with adherence to the timeline strategies in the management of the ACS patients. In addition, the catheterization laboratory facilities should be available in the main hospitals in the country with STMI team ready 24 h, 7 days a week. Ambulance services should be established and activated to facilitate patients transfer well within the right time to the facilitated hospitals. Treatment with tissue plasminogen activator, rather than the streptokinase regimens, should be used in Yemen for earlier reperfusion and more effect in reducing infarct size. ,
The results showed high use of guidelines recommended oral medications, which was similar to other registries.  However, rates of medication like "fondaparinux," Bivalirudin, GP IIb/IIIa and rate of coronary angiogram, Primary PCI and CABG were much lower than those reported in developed and some middle east countries.  Only one government hospital in the capital of Yemen has on-site cardiac catheterization at the time of this registry. Other two governorates have cath lab facilities but were not working on regular basis. This reflect the great need in establishing a tertiary care hospitals with coronary care unit (CCU) and cardiac catheterization facilities that could provide efficient care for patients with ACS. Society awareness, medical insurance and Ambulance services are needed as part of the overall medical care improvement in Yemen.
The overall in-hospital mortality was 8.6%, which was higher compared with the overall mortality in the Gulf, which was 4.6%. This high rate of in-hospital mortality can be explained mostly by the delay of presentation of ACS patients to the ER, high STEMI patient's percentage, prolonged door to needle time, type of reperfusion therapy (SK is the main thrombolytic therapy in Yemen), high selectivity of the patient presented with STEMI and the habit of khat chewing, which proved to be associated with increased risk of morbidity and mortality among patients presenting with ACS. 
The overall long-term mortality was high at 1 month follow-up (14.9%) and was even higher at 1 year follow-up (17.4%). This was higher than the mortality rate in the Gulf in 1 month and 1 year follow-up (7.2 and 9.4%) respectively and much higher than what had been reported in the Euro Heart Survey.  These results might be related to the low-rate of coronary revascularization, poor follow-up and poor patient compliance, khat chewing after discharge from hospitals in Yemen may contribute to this high mortality. Compared to the mortality rate in the Gulf, STEMI patients had higher mortality than STEMI in terms of in-hospital, in one-month and one-year mortality. These findings are common that in the Gulf Registry(3) and published. The higher mortality rate among the STEMI than STEMI may be due to older age and more co morbidity.  A possible explanation of the high mortality among STEMI patients in Yemen is the lack of primary PCI for these patients and khat chewing, which proved to be associated with high morbidity and mortality in patients presented with ACS even with less cardiovascular risk-factors and less co-morbidity. ,
The study did not cover the all hospitals in Yemen and does not reflect the clinical practice of all hospitals in the country.
Many patients with NSTEMI referred to hospital were not involved in the study and therefore not included in the study.
Finally we did not measure the factors that might explain the increase in long-term mortality such as non-adherence to medication.
| Conclusion|| |
ACS patients in Yemen present at a relatively young age with high prevalence of smoking, khat chewing and hypertension. STEMI patients present late, and their acute management is poor. In-hospital evidence-based medication rates were high, but coronary revascularization procedures were very low. In-hospital mortality was high and long-term mortality rates increased two folds compared with in-hospital mortality with the highest mortality in STEMI rather than NSTEACS patients, despite the former being younger and having less cardiovascular co-morbidity. Further studies are needed to explore the underlying reasons for these findings.
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[Table 1], [Table 2], [Table 3]